Healthcare Provider Details

I. General information

NPI: 1508288135
Provider Name (Legal Business Name): TIMOTHY BLAKE B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2014
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 ELM ST SUITE 204
RENO NV
89503-4522
US

IV. Provider business mailing address

343 ELM ST SUITE 204
RENO NV
89503-4522
US

V. Phone/Fax

Practice location:
  • Phone: 775-329-7017
  • Fax: 775-323-0749
Mailing address:
  • Phone: 775-329-7017
  • Fax: 775-323-0749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number283
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: